CHAPTER III It is really the fault of the profession if people do not (Part 1)

CHAPTER III It is really the fault of the profession if people do not as yet understand the nature of professional fees. Some time ago I had occasion to do an appendicitis operation for a gentleman who is known to be generous and of large ideas. The case was one in which gangrene of the appendix opposite to the mesappendix had led to insidious retroperitoneal in- fection. There was no abdominal rigidity, no nausea, and no true peritoneal sign. I was not at all sure that the case was one of appendicitis or that it demanded operation. One of the family physicians, with his record of blood examination in the case and guided by his diagnostic insight, insisted upon operation at a time when I thought it not really necessary and advised against it. The doctor was so impressed that he and another physician in consultation finally persuaded me to operate next day. I started in with the idea of giving our patient the advantage of a short incision which avoids the complication of subsequent hernia. Finding firm old adhesions, a partly gangrenous appendix, and a thick infiltrated mesen- tery with retroperitoneal infection, the operation really called out all of the technical skill and judgment which I possessed. When the time came for sending the bill it seemed to me that a fair charge in the case would be five thousand dollars. This would have been no hardship for the patient, as he had expended more than that amount upon lawyers for investi- io6 TO-MORROW'S TOPICS 107 gating the security of bonds for investment, and it seemed to me a small charge for investigating the security of an operation which might save life or lose it. Our whole procedure in the case was life saving, differing from the lawyer's procedure, in not only saving property but life also. In view of the fact that the diagnostic insight of one of the physicians had furnished the primary motive which led to action and at a critical moment, it seemed to me better to ask the patient to send me one half of five thousand dollars, and to inform him that the family physician deserved the other half. This physician was a man of the very highest character who under no circumstances would have accepted a commis- sion had he been working in association with the kind of surgeon who would have given a commission. Too many of the other sort working in collusion might easily have per- suaded that patient to pay five thousand dollars, beside im- pressing him with a higher idea of value of services, — (more people pleased all around). The family physician sent his own bill for services, as did another consultant. For some weeks no response was made to my bill, or to my letter ex- plaining the circumstances, and I learned subsequently that my patient was offended. Finally he wrote stating that he had made inquiries, and found that the average fee for an appendi- citis operation was one thousand dollars, and that in the case of a member of his family a famous New York surgeon some years before had charged that amount. I learned upon inquiry that the previous case was of an average sort calling for an average fee. The patient was not aware of the special nature of his own case, and could see no reason why it should call for any special charge, although he paid my part of the bill and we remained friendly. As a matter of fact a charge of five thousand dollars for operation for an intra-abdominal infection of almost any sort is a small charge for any man io8 TO-MORROWS TOPICS to whom it means no dq>rivation. Come, now! Who sajrs me nay? This typical case I quote as indicating that the public is not as yet educated to look upon the services of doctors as it looks upon the sen-ices of lawyers. It is another instance of the observation which is often made that property is held to be of greater value than life, as a result of some fundamental instinct. One reason why the instinct remains unmodified is because physicians in their attitude toward a patient introduce a friendly personal interest, and this is at once capitalized by the business man. He finds no such oppor- tunity to capitalize the Geisf of the lawyer. The personal interest and good nature of the doctor having been capitalized are then set by the patient to his own credit account This must always be the case tmless we seriously take charge of a situation in which the esthetic comes into conflict with the economic in our work. The fact that property is held in greater value than human life instinctively is demonstrated in a curious way by people who do not intend to pay their bills. Take, for example, a case of chronic headache. The expense of various tests, examinations and consultations is large because so many ex- perts are required. A man will hesitate to go to all of this expense for a member of his family, and women are noto- riously economical in relation to doctor's bills. People who do not intend to pay their bills, however, will send for the entire list of experts in the most lavish way in a case of this sort. The phenomenon is to be translated in terms of mean- ing that property is held to be more valuable than health by good citizens at least. People do not understand the value of surgical service in a comparative way at all. One day an old acquaintance came in to have a mole removed from his face. It evidently had been troubling his mind for years. I froze the mole with TO-MORROW'S TOPICS 109 ethyl chloride, removing it in a moment. For such a trifling operation for a friend I did not even think of making any charge, but as he started toward the door and asked what my charge would be, I said jokingly, "A thousand dollars." He took it seriously, and asked if I would mind taking his check for five hundred dollars then, and allow him to send the other five himdred a couple of weeks later. We finally compromised by my letting him pay my ordinary ofiice consultation fee of twenty dollars. Some one may say that he was peculiar. That is true in a way, and yet he was a man of means acquired in his vocation as a contractor, and a man who was even accused of shrewdness by rivals. The mole had very likely interfered with his marrying, and what was worse for him perhaps, it had been an obstacle in his daily shaving. A fee of one thousand dollars for instantaneous relief from some- thing which had made him morbid appealed to his state of mind rather than to his habit of estimating comparative values in merchandise. Since that time I have learned that "beauty specialists" actually charge and obtain larger fees than the one which was mentioned jokingly to my friend, and for about the same sort of work. It is probable that beauty doctors make a good deal of ado about the matter when dealing with a vain and silly individual who is fearsome. I once had occasion to do a difficult operation for the son of two good people who had come on from the West. It was a case in which a very good fee would have been permissible. The physician of the family said: "Now, these people are perfectly well able to pay properly for the services, but the old lady is thrifty, and if you send them a bill for more than ^_ one thousand dollars she will make a great outcry and it will ^B hurt me." In accordance with his suggestion, I sent a bill ^H for that amount. One of the nurses. Miss L., told me of the ^B circumstances attending the receipt of the bill. The envelope TO-MORROW'S TOPICS was opened by the careful wife, who was a little near-sighted, and on glancing at the bill she exclaimed, in a tone of distress, "A hundred dollars! My! My! Don't these New York doctors know how to charge!" The nurse replied, "Perhaps It would be better for you to put on your glasses, for I feel quite sure that you have not read the amount correctly." Incidentally I may state that the bill was really paid promptly. In one case in which I charged a man two hundred and fifty dollars for an operation for which another cipher might properly have been added (for saving his wife's life), he paid no attention to my letters for some months, and finally wrote stating that the bill was ridiculous, as I had no reputa- tion or standing warranting any such charge, — in fact, no reputation except for overcharging people. Another man for whom I made a rather moderate charge said, after making objection, "You looked so benevolent that I thought likely you would make no charge at all, but that look of yours is a sort of bunco game." (This work also was for a wife.) I was reminded of a conversation reported from a country dentist's office when an old fellow dropped in to ask about prices. "How much do you charge for pulling out a tooth?" "Two dollars with gas and one dollar without gas." "Say! It don't hurt so terrible bad without gas, does it?" "It only hurts for a couple of minutes." "Well, I guess I'll choose it without gas." "Very well ; take a seat in the chair, please." "Oh, it ain't for me, it's for my wife. She'll be here pretty quick," In relation to bills, one will have good patients and mean ones. Two or three examples will suffice for explanation. I did an amputation of the breast for an old lady in one of the small town hospitals to which I had gone on another case. She TO-MORROW'S TOPICS in could pay nothing for the services at the time, but expressed her gratitude. Some time afterward when I was again in that town she came to me and asked if she might pay her bill with three chickens which were very nicely dressed, neatly packed in a basket, and decorated tastily with daisies. I accepted them with thanks, but heard later that she had been arrested for stealing those chickens. One must not count upon all of his patients being willing to steal in order to pay doctor's bills. Now for one of the other sort. I was very tired, suffering with the grip, and went out to my country place at Stamford late on a February night, determined to have a good full sleep. It was my intention to cut off the telephone, but was too heavy-eyed and weary to do even that. It was a bitter night, with snow and sleet driving and the wind howling along some three miles of drive. About midnight I was called up on the telephone by my friend Dr. W. P. S. in New York, and this conversation ensued. "Please come down to the city to see a case of appendicitis right away. The operation has been done, but the boy is dying." "I am tired and ill, and you had better get one of these other surgeons" (whose names I mentioned). "Two of them have been here and say the boy cannot live more than a few hours." "If that is the case, there is certainly no need for my coming in. They are authorities." Then there was a pause for a moment, and again the doctor said: "The patient's father is here and says he will pay ten thou- sand dollars, if necessary, if you will come in." I decided if he felt so earnestly as that about it, my sleepy fanner would have to be aroused and sent out to a cold barn to hitch the unwilling team on a wild night. On reaching I TO-MORROW'S TOPICS I the city about three o'clock in the morning it was found when the patient had been operated upon, a method that commonly in vogue at that time of packing the abdomen with a mass of iodoform gauze had been employed. The boy was moribund from the combination of ileus due to the packing, and from iodoform poisoning. The doctor was instructed to get in an expert anesthetist immediately, to take out the pack- ing and remove all adherent iodoform by dissolving it with oil, — and I then left and went to bed. The patient made a good reco\ery. I never take advantage of what a man says when he is in distress, and instead of sending a bill for ten thousand dollars, sent a bill for seventy-five dollars, — twenty- five for consultation and fifty dollars for time. The father of the boy refused to pay this bill of seventy-five dollars on the ground that it was exorbitant, because I did nothing and others did the actual work. Three chickens figured in another instance. An old farmer who had a good deal of money because he had saved it, once offered to pay my bill with three prize Leghorn fowls. There were tears in his voice when he spoke of giving me these fowls in payment for services, and I had to relieve his distress by suggesting that he had better take in three hundred dollars from money that he had out at interest and give me that. The fowls were really valuable and no doubt had an intrinsic value of nearly fifty dollars, and a sentimental value in the old farmer's mind far beyond that. I did not doubt his honesty in combining sentimental and intrinsic value in this matter, and his feehng that he was about to make a great sacrifice in bestowing upon me a product to which he had given concentrated thought upon the farm. The instance was simply one of reversal to habitual lines of thought in a man who customarily had found it necessary to avoid paying out much actual cash. Doctors have so many peculiar experiences id that ■ lat was 1 TO-MORROWS TOPICS "3 in regard to the payment of their bills that it would be difficult for them to remember all, and I have quoted just a few for purposes of lighting up the narrative a bit. There is no doubt but the best time for collecting a bill is when the responsible party is engaged with the fear group of emotions, in advance of an operation. Patients often pass sleepless nights, and occasionally commit suicide, because of the fear of the ordeal of a surgical operation, but a few days after the work has been done the patient says: "Pooh, that was nothing!" While understanding the psychology under these circumstances, I have never cared to make practical application and take any advantage of the situation. Never- theless one cannot disapprove of surgeons who do take such advantage. If they really render valuable service and are properly and promptly paid, both parties are pleased. If one waits until the fear group of emotions has entirely faded away, and leaves the matter of his bill to the calm reasoning of the patient, the latter is very apt to revert to customary modes of thought which include protection of his present interests. Gratitude commonly belongs chemically among the It lighter hydrocarbons and follows their laws of diffusion. It is very difficult sometimes to know how much to charge for services if one does not wish to cause any hardship. A patient came in from the South, for whom I divided a deep and troublesome stricture. The result might have properly called for a good fee. I had no means of knowing the man's circumstances but judged from little things that a fee of two hundred and fifty dollars would be all that he could pay with- out deprivation. When that was quoted he was overjoyed, and at once sat down to make out a check, remarking at the same time : "You people in New York have treated me mighty white. When I came up here they told me that you would not look at me for less than a thousand dollars, and you might 114 TO-MORROW'S TOPICS charge me five thousand, but here I am getting out of the whole thing for less than five hundred dollars." On one occasion I went to a distance for an emergency operation upon a woman with tulial rupture, saving her life outright. When preparing to leave, her husband asked what my charge would be. I had no means whatsoever of knowing about his circumstances, and asked him directly what they were. He said that if all he owned were added up it would amount to about ten thousand dollars and he had three thou- sand dollars a year salary. I said, "You can pay me five hundred dollars to cover operation, time and expenses." This was not a fair fee for the sort of work which had been done, but it was one which would be fair under the circumstances which he related. I learned subsequently that he had stated the truth so far as he was personally concerned, but his wife was wealthy in her own right, and could readily have paid a proper fee. A man will often spend many thousands of dollars in various trips to European health resorts in order to be treated for some internal trouble which is curable by operation. Then when he finally tires of procrastinating, he will object to paying for the operation a tenth of the amount which he has previously expended fruitlessly. One reason why he prefers to expend the large amounts in travelling about is because there is always pleasure incidental to making such expenditure, and it is a sort of long drawn out vacation. There is no need